HomeMy WebLinkAbout10185 vuc�a�e��coM�usarroai oec�+tanrroa V2-0091 DFW 7/B]
d hereby.aftirm that 1 hove a car�ificaro af corisent to self � �
inswe,or a cntifimte of Workars'Compensation Insurance,or ��+baso
o certified copy thereof(Sec.3800,La6�i, ��.( `EB� ppp4lCATf4N FOR PERMIT
Palicy No.��' '`ompany �.41��`�F�J4l. �i
❑Carrified copy is hereby furnished. SEWER • SEWAGE DISPOSAL
❑Cerrified copy is tilad�h 1 e counry building inspection COUNTY OP tOS ANGELES BU�LDING AND SAFETY
departmenl. � � "� '
Dm��Applicont � ~ �°+i�-- POR APP4ICANT Tp FItL IN CGNNECTION�ATA
CERTIFICATE OF EXEMPTION FROM WORKERS' euuawc )"� i �� srnnoN oearH
COMPENSATION INSURANCE � nooacss �rf
(This section naed nol be completed if the work involved by the tocnurv _� MANHOLE REFEREN^.E u°°ER
permit is for one hundred dollars($100)or less.)
NEAREST � TYPE OF CONNEGTION lENG1H FItOM
I tertify thot in ihe performance of the work for which ihis crzoss si, �, v. Nae P.L. M.L TO P.L.
permit is issued,I shall not employ any person in any manner p
so as to bacome subject fa the Workers'Compensmion taws. pu,NER .co.iMa.No. ioe No. 6 a�
MAIL f '.TRUNK PERMIi NO. ROAO PERM�T NO.
Dme Applicanf nooaess z1� � u,«.-�. .
NOTICE TO APPLICANT: If, afier mokin ihi5 C9f11fiCO1C O{ � � � AFFIDAVIT WAIVER EASEMENT RECORD.INSTfi.NO. PATE
9 CITY , F(, TEL ND.
f+��amp�ion, you should 6ecome subject to the Workers' iecai
` �pensation provisions of ihe Labor code,you m�si forthwilh DESCR:PTION tOTNO. HWY.ORST.WIDENING
�_.nply wi�h such provisions or�his permir shall 6e deemed
revoked. eiocK TRACT STAiE ENCROACHMENT
LICENSED CONTRACTpRS DECLARAT�ON .oF aiocs. r�aMi*No.
I here6y affirm�hm I am li<ensed under prov�sions of Chapter sizeoFior NowoN�oT
use or r
9(commencing wifh Section 7000)af Division 3 of the Busi- BUaDiNGs o�aaGEs
ness and Professions Code,and my license is in foll Force and �
B{fOC�. A CONTRACTOR / -4 CONNECTION CHARGE FEE
License Numbe���liC.C�a53 /�_ � , �� � REIMBURSEMENT iEE a
ADDRE55 �
/� •+� / /[� - OiSTRICi NO. GROUV MAP PF'JCESSED BY O
Contrac�or 'fmJ�1 Dare���s nn . l_q..J. Tei,No, ',.J'r' 'r�� U
STATE /� UC J BK iG Z
❑I om exempi under Se. of IMe L.A.Ca uceNse no. p!� ctn55 `'7 O
Plumbing Code and/or Sec. af ihe No. oeSCR�PtiON OF WOR�c �e fiNAi ~
FfOUSE SEWER CONMECTING i0 � '"j� OAiE U
PUBl�CSEWER �� VALIDATION W
8.&P.Code for the following reason � �� vai
` �// $EPfIC TANK,SEEPAGE PIT OR FINAI ?
Date t-1��`lJ6/ vli5 AND/OR DRAINFIESD BY
HOUSE SEwER CANNECiING i�
� (n�� PRIVRTF DISPOSAL SYSTEM
Signat��e� ��f,r 1`�- � - CONNECTA�OITIONAtBL�G.OR ,
OWNER-BUILDER DECLARATION woaK To House sexes
OVERFIOW SEEPAGE Pli,ORAINiIELD
I here6y affirm that I om exempt from the Comrottor's License exiN.,Ce55Poo�.DzvwEu,MnNNaE .
Law for the following reason(SeCfon 7031.5,BUISnBss ond P�O- AtTER,ftEPAIR OR ABANDON HOUSE �f?,'rj fy C/{�
�"'^iOnS COCJEJ: SEWEROR OISPOSAl5Y5TEM
,I,as owner of the property,or my employees with wages as #`� • • • � �
their sola compensation,will do ihe work and fhe strocture . �
is not intended or offered for sale(Section 7044,Business � ' �2������
and Professions Code). OFNNER�S Permit S � bD
�,I,as owne�of�he property,am exclusively cororacting with AUTHQRIZATION TOTAL FEE ��, ��Q � � ��7�'C�`T'
�iCBI15@C�coniroctors to consfruct the projacl($ection 7044, i nqVE aT rHis�ATE A CONTRACT WITM iHE NEREIN NAMED CDNiRACTOR i0 �h a'���F
BVSifIf55 Ofld PlOFB5510f15 CO(�2�. CONNER THE ABaVE DESCRIBiD E%ISTING DWftLING i0 THE VVBIIC SFWER.
CONSTRUCTION LENDING AGENCY �� �� p�-� �
I hereby affirm �hat there is a construction lending agency SIGNEDTHIS 0 OF 194.p.
for Ihe performance of the work for which this perm�t is ownea�nc€rvt } . �`Y
issued(Sec.3097,Ci�C.). i �i '� �
nooeess�7 [7 z, l. ,;,/1L ' rt-f.f�.Kt-+Lbt.(f�.
Lender's Name
lende+'s Achlhess - lJ
I certify fhot I hove reod is opplication and state ihat ihe
above information is wrr .I agrae to comply wilh all County
wdinonces osid Sfafe laws regulating Piumbing dnd Sewers,
and hereby authorize repreaentalivas of this County ro entar
upon the above-men7ioned properry for inspection purposes. �
�,�,�s�`�i.�.�e .3-alr- 51�''
$ignature of PermiNee Date SF6 REVERSi PON E%PLANATORY IANGUAGE
. . _....._ ...
5
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DATE ��PF�TOR'S S�dRiURE
APAR'Q1V ALS �� i h�r�by a z a t4e.I a� c���fi,n t i+t cr;.tae c�.-'c
�' �� � Licc.n �.Law f s u f�1 in c�. �x( . .�7u97 y,
NEW HOl15E 5[yvLR (�— � Bcas�.es� a c's ra,e�E . C� J� �� er<zi:ly
CONNE�SAQ3ITIONA. ( � f(.}�t ft..,��tY 3�t i.- e� $ t .���. �, : � at:,
ILCINGO�WOiY, ,'
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thw stzactttt�is um�.+r.:e�mde��x offr.yc.:Ez�:,4?�. .-.�
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� frt�pveiy trlh3 bH%&is ar i-.f•ra^�r�tf:Tr��u-..�,r^,h`znf.-�cti-=t�
� . apt'J1 fs�nrk Si�,Mn_•wra4sl t$W swen iwr�.r�:-=�.-we-�rss
. ar�aot iMvaAaf or c;lvad�or s=lc.i:;(-.>•.--�,.-r, tfi�e
. . . � bwiJCPArg or il�sgrrt�t�e�sNw3' f; ;e�'d u.w3l-r r-:�y::.ar pj
- --- __._......_. conqpleeiaa�, tb.; o�;�Kav.�!'?r,- . t!--�. L�..,-rnr.
� of provir�tl�nt k�e did r:rrr E�dtr'��or�i.,�.,=:,r;c���30��alie
_..__..�___�. P�+Y�o�I�l
_^ � �am eAcemgt tx�sc}�5�e€.��_----_—,
_ ��P.C.fot this re��,t;------_____—
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